NOTE ON THE PARALYSING ACTION OF ACONITE ON THE SYMPATHETIC NERVE. BY FREDERIC BAGSHAWE, M.A., M.D. CANTAB., M R.C.P.L. THE topical action of aconite was displayed in the following case in so marked a manner as to be worth recording. A young lady, aged nineteen, came under my care in November 1872, who had long been suffering from spinal irritation and neuralgia. During the previous summer she had passed some time at St. Moritz with benefit, and could then walk four or five miles. A recurrence of severe pain, sometimes in the spine, and sometimes in the face, head, and neck, had induced her to seek further change at Hastings. On the 3rd of November, having recovered from an attack of spinal pain, the patient took a short walk while a north-east wind was blowing, and came home with severe pains in the head and neck, chiefly on the left side. The effect of the subcutaneous injection of grain of morphia was to induce sickness, while it failed to relieve pain or to procure sleep. Liniment of chloroform and belladonna was applied, but she passed a disturbed night, and next day was suffering much pain along the course of the left occipito-cervical and trigeminal nerves. I applied the liniment of aconite (B. P.) behind the left ear and down the neck, carefully avoiding a small place which had been blistered by the chloroform liniment. Some relief was obtained, and the liniment was again painted on twice that day (5th Nov.), and produced some numbness and tingling of the lips. On the morning of the 6th more liniment was applied, as this was found to be "the only thing that drove away the pain." At 9 A.M. the eyes and nose felt sore and tingling "as if she had a cold in the head;" at 1 P.M. burning soreness of the eyes was increasing, the skin of the neck was numb, and the lips tingled much; at 3 P.M. she was screening her eyes from the light, but rejoicing in being free from the neuralgia. The left eyelid was much swollen. The vessels of the ocular conjunctiva were enlarged, bulging, and tortuous, and of a bright pink hue. The forehead, face, ear, and neck were hot to the touch, while the right side was cool. The pupil was widely dilated, and vision was greatly impaired, so that she was unable to read good letterpress, but could read large print of a title-page. The lips were dry. The tongue was projected somewhat to the affected side. This was tried twice. There were no general symptoms, no weakness. The pulse was 88. At 6 P.M. pain in the eyes and intolerance of light were still greater, but she was free from neuralgia and perfectly well, the eyes excepted. The pupil being widely dilated, I examined with the ophthalmoscope, and saw the arteria centralis distended and the retina generally congested. Sensibility, tested by pricking, was greatly impaired over the whole of the side of the neck and face to which the aconite had been applied. The symptoms abated at 9 P.M., and next morning (11 A.M.) the congestion of the eye had almost subsided, slight redness and swelling only remaining. The left pupil was still larger than the right; both contracted well to the stimulus of light. There was no return of neuralgia. It is not uncommon to meet with less marked cases of the effects produced by the topical use of aconite, thus: Mr. W. S., aged 50, suffering from facial neuralgia, rubbed aconite on the cheek-bone. It caused numbness and "twittering" sensation of the part, which lasted some hours, while the pain was dulled. There was sensible increase of warmth of the muscles of the face. The eye became weak and watering, while the lid drooped. The state of the pupil was not noted. This condition lasted about twenty-four hours. Mrs. W. D., aged 57, used aconite liniment with temporary relief to her neuralgia, and with increased warmth to the facial muscles and manifest congestion of the conjunctival vessels. These and similar cases point to the fact that aconite applied to the skin in the neighbourhood of the cervical ganglia and branches of the sympathetic, produces consequences similar to those brought about by section of the nerve in that situation in animals. In both cases a swollen and congested state of the conjunctival vessels and abnormal warmth of the part is the result. In both the threefold office ascribed to the sympathetic is interfered with: (1) sensation is blunted in the parts supplied by the nerve; (2) nervous control over the blood-vessels is withdrawn; (3) motive power is reduced. Aconite thus becomes a powerful local remedy in our hands, not only as a controller of morbid sensation, but as a retarder of vascular action, and by consequence as a modifier of muscular action. But although generally a painless remedy, is it a safe and innocuous one? Happily, it appears that the small quantities of the drug capable of being absorbed through the skin, attack the nerves and muscles directly in their neighbourhood, and show little disposition to be absorbed into the general current of the circulation, and so paralyse the great central circulating organ. In the above detailed case the local action of the remedy was powerfully exerted, but neither stomach, kidneys, nor heart seemed to sympathise. None the less, however, is caution needed in the use of so powerful an agent, lest its action should pass on to the cardiac nerves and vessels, and so produce grave symptoms. The following case of general aconite poisoning illustrates some of these symptoms, and shows at the same time how large an internal dose of aconite may be recovered from. In December 1871 Mrs. G. was attending the Hastings Infirmary as outpatient, suffering from pain in the shoulder, and was ordered a liniment composed of equal parts lin. opii and lin. aconiti (B. P.): she was duly cautioned as to the poisonous nature of the application. On January 5 she drank off about six drachms of the liniment, i.e. three drachms of lin. aconiti. Immediately afterwards she felt a burning sensation in the throat and tongue; in about ten minutes she was unable to speak, and is said to have made a stertorous noise in breathing; she suffered from a strangling sensation in the throat. The face was partly pallid, partly flushed (over the cheek-bone). A neighbouring chemist who was called in encouraged vomiting, which had already set in, with mustard emetics, followed by 3ss of sulphate of zinc: he did not yet know what poison had been taken. I saw the patient an hour and a half after the dose had been taken; she was then agitated and weak, with a pulse of 84 and a cool skin; her only complaint was of burning at the throat and stomach, and weakness. The pupils were larger than natural. She took some brandy and raw egg, and a stimulating draught from time to time. Next day she felt faint and low, and some amount of burning sensation in the throat and stomach continued; the face was flushed, the pulse 80 and good; the urine remained. normal, and much milk was secreted. On the 7th she appeared to be well. In cases of fatal aconite poisoning the symptoms seem to have followed this order : 1. Tingling and numbness of the tongue and throat, soon extending to the stomach, with local sensations of heat. 2. Failure of the circulation, evidenced by cold extremities, cold sweats, great feebleness, &c. 3. Pupils dilated and sight dimmed. 4. Fatal syncope. [As a pendant to Dr. Bagshawe's cases of the local action of aconite upon the vaso-motor nerves, I beg to mention the following, which occurred some months ago in the out-patient room :-E. M., a small and thin woman, aged 29, married, but has never had children: she had had threatenings of phthisis, and had also suffered intercostal neuralgia. Just after Dr. Bagshawe had informed me, verbally, of his first case, this woman applied one day at the hospital, suffering from severe pain in the left trigeminus (first and second division), which was evidently excited by a very bad carious tooth. She would not have the tooth extracted, and, as an experiment upon the powers of aconite, I ordered the lin. aconiti to be painted over the painful parts. The effect in arresting pain was immediate and complete, but on the next hospital day she came complaining of erysipelas." The parts which had been painted were swollen and bright red; moreover the conjunctiva of that side was severely congested, with tortuous vessels. The pupil in this case was contracted rather than dilated; and this leads me to notice the curious fact that in Dr. Bagshawe's cases the pupils were dilated, in his first case to a remarkable extent. I need not say that, while the rest of the phenomena agree well enough with the idea of sympathetic paralysis, dilatation of the pupil is exactly the reverse of the condition of iris produced in Bernard's and Brown-Séquard's experiments.-F. E. ANSTIE.] |